Colorado’s Cannabis Safety Net Fails: Critical Delays in Warning Consumers About Dangerous Products

In March 2022, a disturbing pattern began to emerge from Colorado’s public health offices: reports of severe liver damage were increasingly being linked to 1906 Midnight Drops, a rapidly ascending star in the state’s burgeoning marijuana-based sleep aid market. This alarming trend, however, would not trigger a public safety alert from the state’s Marijuana Enforcement Division (MED) until June 2023, a staggering 15 months later. By then, the danger had escalated to such a degree that the manufacturer, Sima Sciences, had already ceased production of the popular pills following a surge in "acute liver injury" complaints. This significant delay underscores profound systemic weaknesses within the regulatory framework designed to safeguard consumers in the nation’s pioneering recreational cannabis market, leaving individuals like Jenifer Chatting facing life-altering health consequences.

The trajectory of 1906 Midnight Drops, from a lauded "natural" sleep solution to the alleged cause of severe liver damage, casts a stark light on the vulnerabilities of a rapidly evolving industry. Colorado, a trailblazer in legalizing recreational marijuana in January 2014, set a precedent for other states, but its regulatory infrastructure appears to have lagged behind the market’s innovation and expansion. The state’s initial efforts to manage cannabis largely focused on establishing a controlled market, revenue generation through taxation, and preventing illicit activities. However, the unexpected health crisis surrounding Midnight Drops has brought to the forefront the critical need for robust, proactive consumer protection mechanisms, particularly in a domain where products are ingested and can have profound physiological effects.

A Personal Tragedy: Jenifer Chatting’s Ordeal

For Jenifer Chatting, a 53-year-old surgical assistant from an oral surgeon’s office, 1906 Midnight Drops represented a hopeful alternative to traditional pharmaceuticals for her chronic insomnia. Seeking a safe, "all-natural" remedy, she turned to a local marijuana dispensary in March 2022, the very month state health officials first began receiving reports of liver damage linked to the product. The manufacturer, Sima Sciences, aggressively marketed Midnight Drops as "the best sleep aid on the market," a blend of cannabis and herbal extracts. Unaware of any impending dangers or the state’s nascent investigations, Chatting began a nightly regimen with the drops.

By September 2022, approximately six months into her use, Chatting experienced troubling symptoms, including full-body cramps and new-onset lactose intolerance. She dismissed these as minor issues, attributing them to simple dehydration. The lack of clear, public warnings meant she continued consuming the drops for another nine months, only stopping when her dispensary ceased stocking the product. It was not until September 2024, more than two years after her initial symptoms and a year after discontinuing the drops, that a routine lung screening revealed a grim diagnosis: cirrhosis of the liver. Her medical records confirmed no prior history of liver problems, and her gastroenterologist ruled out alcohol, pointing directly to the herbal sleep aid as the probable cause. Chatting now faces the daunting prospect of a liver transplant within five years, a future irrevocably altered by a product she believed was benign. Her husband, Luke, expressed profound anguish, describing his desperate internet search that finally uncovered the MED’s buried notifications, leading him to exclaim, "Jen, they killed you." The couple is currently suing Sima Sciences, which has denied their claims and cited "comparative negligence" in court filings.

The Product Under Scrutiny: Midnight Drops and its Ingredients

At the heart of the crisis were the ingredients of 1906 Midnight Drops. Sima Sciences initially formulated the pills with corydalis, an herbal extract advertised for its sedative qualities and pain-relieving properties, boasting "millennia" of traditional use. However, corydalis, a relative of the poppy, contains a compound scientifically linked to severe and potentially fatal liver injury. Following initial reports of adverse events, Sima Sciences reformulated the product. Yet, regulators eventually concluded that the new formulation primarily contained a compound with the same chemical makeup as the liver-toxic element found in corydalis, effectively replacing one problematic ingredient with another structurally similar one. While a warning label was added, advising consultation with a physician, the underlying risk remained.

Dr. David Cristin, a gastroenterologist, observed a troubling "uptick in patients with elevated liver enzymes" directly linked to Midnight Drops, reporting four such cases to the enforcement division in December 2022 and noting that other doctors were seeing similar trends. His exasperation grew as patients continued using the drops, unaware of the potential harm, often "swearing by these" for their sleep benefits. Despite his attempts to register a complaint through the company’s website, he received no contact, highlighting a breakdown in direct communication channels between medical professionals and manufacturers, as well as with regulatory bodies.

A Protracted Regulatory Response: The Timeline of Delay

The timeline of regulatory action in the Midnight Drops case reveals a disconcerting pattern of delay and insufficient public warning:

• 2019: Sima Sciences launches 1906 Midnight Drops. The state attorney general’s office later discovered that the manufacturer began receiving internal complaints of harm shortly after this launch, years before state officials were aware.
• March 2022: Colorado public health officials receive the first reports of liver damage directly tied to Midnight Drops.
• July 2022 (4 months later): The Marijuana Enforcement Division (MED) posts an "informational notification" on its website. Crucially, this was not a "health and safety warning," which would have explicitly advised consumers to stop using the product. The notice stated that while "adverse health events" had been reported, regulators found no violations, and the manufacturer had "reformulated the product," with "no additional issues" having surfaced. This understated communication failed to convey the gravity of the situation.
• December 2022: Dr. David Cristin reports a continued "uptick in patients with elevated liver enzymes" to the MED, expressing strong belief that Midnight Drops was the cause.
• May 2024: The Colorado Department of Public Health and Environment (CDPHE) records 52 reports of harm related to Midnight Drops, with at least 20 cases severe enough to require medical care. A significant 25 of these reports occurred before the MED’s second, more explicit warning.
• June 2023 (15 months after first state report): The MED and CDPHE issue a second notification, finally classifying it as a warning about "acute liver injury." Sima Sciences simultaneously announces it is stopping production.
• Following June 2023: Despite halting production, Sima Sciences and its associated companies continued marketing Midnight Drops for several more months and failed to adequately inform dispensaries to cease sales, as revealed by a later investigation by the Colorado Attorney General’s office.
• September 2025: Peter Barsoom and Sima Sciences reach a settlement with the Colorado Attorney General’s office, agreeing to pay $400,000 in fines and are barred from selling cannabis products in Colorado until at least 2027. They also issued a public apology.

This extended period between initial reports of harm and decisive regulatory action left consumers like Jenifer Chatting exposed to a hazardous product, unknowingly jeopardizing their health.

Colorado’s Regulatory Framework: A Web of Weaknesses

The Midnight Drops debacle is not an isolated incident but rather indicative of broader systemic vulnerabilities within Colorado’s cannabis regulatory structure. A joint investigation by The Denver Gazette and ProPublica found that Colorado’s Marijuana Enforcement Division has historically operated with limited authority and a reactive posture, contributing to significant delays in consumer warnings.

1. Limited Enforcement Power: Prior to a 2023 statute change, the MED possessed limited power to compel companies to recall products. Recalls could only be forced for specific violations, not merely on the basis of emerging safety concerns. This meant regulators had to build a complete case of violation before taking strong action, a process MED spokesperson Heather Draper described as complex and time-consuming. However, critics argue that in health matters, "time is of the essence." Thuy Vu, Denver’s former head of marijuana inspections and enforcement, stated that a seven or eight-month delay is "ridiculous," especially given that reported safety problems are often just a fraction of the actual harm.

2. Delayed Warnings: The investigation revealed that, for cases where complaint or investigation start dates could be identified (23 out of 83 advisories over five years), it took regulators an average of over seven months to issue a public warning. This timeframe is particularly concerning for products like edibles or smokables, which are typically consumed within days of purchase. In stark contrast, the U.S. Food and Drug Administration (FDA) has been criticized for taking an average of two months to issue warnings and initiate recalls for contaminated food, a sector with established, robust protocols. Kimberly Anzarut, a former Denver marijuana regulator and industry consultant, emphasized that these delays render warnings ineffective, as "people have already consumed the product."

3. Data Opacity: The MED’s refusal to release comprehensive data on when investigations began, citing ongoing probes even years after warnings were issued or licenses surrendered, hinders public oversight and a full understanding of regulatory efficiency. This lack of transparency further complicates efforts to analyze and reform the system effectively.

4. Flawed Testing Procedures: Colorado’s system relies heavily on an "honor code," allowing manufacturers to choose their own samples and the labs that conduct contaminant tests. This contrasts sharply with 26 of 42 state marijuana markets, which require independent labs or contractors to collect samples, thereby reducing potential conflicts of interest or manipulation. A proposal in January to adopt such a system was shelved due to resistance from top manufacturers concerned about increased costs.

   

5. Reduced Testing Loophole: Colorado also permits manufacturers to test products far less frequently if they demonstrate "consistent compliance," a period that can be as short as a few weeks. Regulators themselves acknowledged in a 2023 industry forum that this program "potentially poses risks to public health and safety," noting that problems with it were "a common occurrence" in investigations, leading to recalls for unsafe pesticide levels.

6. Lack of Proactive Sampling: Historically, Colorado has relied on consumer complaints to identify tainted products already in the marketplace, rather than employing random sampling of products on dispensary shelves. While the Cannabis Regulators Association recommends random sampling, and states like Oklahoma have implemented it, Colorado only launched a pilot program this year, which has faced delays and lacks long-term funding.

7. Ineffective Recall Mechanisms: Even when contaminants are identified, manufacturers often continue selling products while challenging findings. Colorado’s rules allow manufacturers to retest marijuana without a specified timeframe, and the MED "may" require a sales halt during retesting, but it’s not mandatory. This contrasts with states like Missouri, which immediately place a hold on all products failing contaminant tests, preventing sales until retesting definitively proves the original analysis incorrect. Colorado regulators have noted "increased instances" of manufacturers exploiting this retesting rule to conceal the use of banned pesticides.

8. Organizational Alignment: Tess Eidem, a research professor at the University of Colorado studying the MED’s health and safety bulletin process, raised concerns that the division’s placement within the state’s revenue department, rather than its health department, might prioritize the financial viability of the marijuana market over consumer safety. While MED spokesperson Heather Draper asserted that "consumer safety has been and remains a top priority," the structural placement invites questions about potential conflicts of interest.

The Architect of Midnight Drops: Peter Barsoom and Sima Sciences

Peter Barsoom, a former Wall Street financier, founded Sima Sciences in 2014, aiming to elevate the cannabis market with high-end, precisely dosed products under the 1906 brand. His vision, a nod to the 1906 Pure Food and Drug Act, positioned his company as a leader in safe, regulated cannabis. By 2023, Sima Sciences had become a dominant force, manufacturing 81% of the cannabis pills sold in Colorado dispensaries.

However, Barsoom’s emphasis on regulatory compliance was reportedly challenged internally. Thuy Vu, a former head of regulatory compliance for Barsoom, claimed she clashed with him over his desire to "bend the rules" on inventory reporting and product safety, leading to her dismissal in 2016. While Vu clarified she was unaware of the Midnight Drops issues, which arose after her departure, her account suggests a pre-existing tension between corporate ambition and regulatory adherence.

In response to lawsuits, Sima Sciences and Barsoom consistently denied wrongdoing, attributing any injuries to "plaintiff’s own comparative negligence." The settlement with the Attorney General’s office, however, speaks volumes. The $400,000 fine and the prohibition from selling cannabis products in Colorado until 2027 represent a significant consequence for the company. Barsoom’s apology, issued as part of the settlement, stated, "We are sorry that we didn’t act faster and communicate better with both our customers and regulators." For victims like the Chattings, this apology rings hollow, underscoring the irreversible damage already inflicted.

Broader Implications and the Path Forward

The Midnight Drops saga is a critical case study for the entire legalized cannabis industry, both in Colorado and across other states that have followed its lead. It highlights the inherent tension between fostering a new, revenue-generating industry and ensuring robust public health safeguards. The delays in warning consumers, the structural loopholes in testing and recall procedures, and the organizational placement of the regulatory body collectively paint a picture of an underdeveloped safety net.

The human cost, exemplified by Jenifer Chatting’s devastating liver damage, serves as a poignant reminder of consumer vulnerability when regulatory oversight falters. Luke Chatting’s frustrated question, "How are people supposed to know this? The only way I found this stuff was by digging and digging and digging on the internet," resonates deeply with the core failure of public health communication.

Moving forward, Colorado, and indeed all states with legalized cannabis, must prioritize fundamental reforms. These include:

• Strengthening Regulatory Authority: Granting agencies like the MED clear, proactive power to issue immediate holds and forced recalls based on emerging safety concerns, rather than waiting for full violation confirmation.
• Enhancing Testing Integrity: Implementing mandatory third-party, independent sample collection for all cannabis products, removing the "honor code" system. Re-evaluating and tightening rules around reduced testing programs.
• Proactive Market Surveillance: Establishing and adequately funding random sampling programs for products already on dispensary shelves, moving beyond a reactive complaint-driven system.
• Streamlining Communication: Developing clearer, more accessible, and timely public warning systems, ensuring that "health and safety warnings" are issued promptly and prominently, not just "informational notifications."
• Re-evaluating Regulatory Structure: Considering the placement of cannabis regulatory bodies within public health departments to ensure that consumer well-being is unequivocally the primary mandate.

The promise of a safe, regulated cannabis market hinges on unwavering commitment to consumer protection. The tragedy of 1906 Midnight Drops and its victims demands that regulators learn from these failures and construct a safety framework as robust and innovative as the industry it oversees, preventing future harm and restoring public trust.